Taking Care of the Uninsured: A Path to Reform (review)

In 2009, the United States entered the worst economic recession since the Great Depression, the result of a confluence of factors including a sub-prime mortgage crisis, a collapse of the housing market, rising oil prices that translated into inflated prices for consumer goods and reductions in purchasing power, and a continuing sharp rise in health care costs. Corporations once deemed invincible were labeled by the federal government as "too big to fail" as a precursor to being bailed out. Few places were as hard hit as Detroit, Michigan, which for much of the 20th century had depended on the now-faltering automobile industry. Tens of thousands of jobs were cut, and the ranks of the uninsured swelled. Detroit provides the perfect case for examining the perils inherent in a system reliant on employer-based insurance—when the economy heads south, the system ceases to work, and counter-cyclical programs such as Medicaid are forced to cover more enrollees at a time when revenues are dwindling. It is truly a backwards arrangement.

Three of the five authors in Chesney et al.'s Taking Care of the Uninsured: A Path to Reform call Detroit home, and the others live elsewhere in Michigan. The book focuses on the Voices of Detroit Initiative, or VODI, as a practical local model for covering the uninsured, with lessons for national health reform that rely on joint federal, state, and local efforts. In some ways, as is inevitable given such a volatile topic, the book is already dated. It discusses the State Children's Health Insurance Program (S-CHIP) debate between then-President Bush and Congress, and notes that "a national solution to [the health care] predicament is not imminent" (p. ix). With this context, the authors argue for state and local action to cover the uninsured. Yet, as this review is written, comprehensive health care reform legislation is being drafted by both chambers of Congress. In fact, by the time this review goes to press, it is very likely that we will know much more about the political feasibility and prospects for reform than we do now. Indeed, the fate of national reform may already be sealed by the time you read this. Despite this changing landscape, many of the lessons in this book are sure to prove timeless.

The book includes six chapters and two appendices. In the first chapter, entitled "Answering the Call: Providing Care to the Uninsured," the authors define the problem of the uninsured in the city of Detroit, describe briefly the efforts of stakeholders in the community to unite in forming the VODI model that provides the case study for the book, and provide an outline for the remaining chapters. Put simply, the VODI model relies on implementation and organization of the "4 Cs"—collaboration, coordination, coverage, and care—with the goals of reducing emergency room use and inpatient hospitalization, while increasing primary care use through adherence to a medical home model.

The next four chapters lay out the details. The challenges of collaboration and coordination—how building trust between community stakeholders was an arduous task lasting nearly two years—are discussed, and the technical side of implementation is explained. Unfortunately for the reader, the account reads more like an historical narrative than a guide on how to follow suit in one's own community. Fortunately, however, each chapter concludes with a concise explanation of lessons learned. This certainly helps to boil down what is at times a very dry book into easily digested pieces. Additional assistance comes from Appendix B, which provides a crash course in analytic methods used in the text.

The authors provide a detailed explanation of the enrollment process—first determining eligibility for public coverage, then enrolling individuals the VODI program. The authors report that this process alone was quite valuable in identifying a number of individuals who were eligible for, but not...